1984, 07-09 Permit App: 00001070 Residencey 3QL/ G~v
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please return this original and your building plans to the Department of Building and Safety)
1 Owner's Name ,,,,, (last) , (first) (m)
: ,>. s _ 11 .�-dt_ a.
Department_Use�nly
Res. v Comm
2 Project Ad�drr�; (not Mailing AcjF7ress) or Road Na Space Zip
3V sip0 .DSC.
3 City/Community
spate l
Subdivision/PlatNaamwe
4 A6seesor Parcel No.
l 3�cq 1 _ eke.d-
✓-'
Lot
/1'
Block
7
* * * DEPARTMEE/NyT�USE ONLY * * *
5 Sic Code
Zone Act. #
Zone �� �—
Project No. ( "
6 Dwell k
��
No. of Buildings
Sq. Ft./Acre
Depth /
/-
Frontage
el°�
7 Set Back -Front (L)S-1 7
a- 1
(R)S-2
Reartc t
41.
(bnsu9 Tract
Module No.
Is
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
tractor Firm Name
�'{ ; ; l '+e,, v'1` C
Street Address
,` S/ "7 his .f�;�,/� t� • t: <
Zip i
jPerson
Clt�y``
tate
PhonePhone ?,,,,e-
tact License No.
alb .r& t .. ` ". IFL—J - �°j c-- ic... i1
t�
Phone If different than above
( )
Owner/Age t (if different than S1 abov))
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Ch� C/N)
J
Other (YINN)S
`I/
SEPA Exempt (Y/N)
Date
15 Type Work ii/ Bldg
❑ Fire
El MH
❑ Demo
X New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
I GOO ' KA r
6.24 41
E
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration/addition
APPLICATION #
Conditions/Comments• —� Ek.r+
Release
Release w/cond 1
Hold 2
Ng -
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/Comments•
Engineers: ❑ Commercial; ■ • sidential;
N. 811 Jefferson ❑ drainage
❑ road improvements
Conditions/Comments•
new access/approach;
❑ Flood Plain;
❑ fence;
',yet
Utilities:
N. 811 Jefferson
Conditions/Comments'
Other:
El
Plan Exam
Fire Prev.
Conditions /Comments*
Project Representative
Agencies Performing Special Inspection:
1
Telephone
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
2»//i Ln
1_b-1- 2 L k R A cic{n .